week 8

15

Improving Medication Reconciliation to Reduce Polypharmacy in Older Adults

Shabnam Mashinchi

Azusa Pacific University

GNRS 567

Professor Sheryl Nespor

October 27, 2026

Improving Medication Reconciliation to Reduce Polypharmacy in Older Adults

Polypharmacy is a common concern among older adults, especially those with multiple chronic health conditions. As people age, they may take several medications for conditions such as hypertension, diabetes, and cardiovascular disease. Older adults may also receive prescriptions from different healthcare providers and use over-the-counter medications, vitamins, and supplements. Managing multiple medications can become complicated and may increase the risk of medication errors, drug interactions, and other medication-related problems.

Medication reconciliation is an important process for improving medication safety. During medication reconciliation, healthcare providers review the medications patients are actually taking and compare them with the medications documented in their electronic health records. This process helps identify medication discrepancies, duplicate medications, potentially inappropriate medications (PIMs), and medications that may no longer be necessary. For older adults who receive prescriptions from multiple providers, regular medication reconciliation may help prevent medication-related problems and improve medication management.

The proposed intervention will focus on implementing a structured medication reconciliation process at Avicenna Medical Clinic, a primary care setting where older adults receive care for chronic health conditions. The target population will include patients aged 65 years and older who take five or more medications. During primary care visits, healthcare providers will review prescription medications, over-the-counter medications, and supplements, compare them with the electronic medication list, and identify discrepancies or potentially inappropriate medications. Medication concerns will be discussed with the prescribing provider, and patients will receive education about their medications and any recommended changes. The goal of this intervention is to improve the accuracy of medication lists, identify unnecessary or potentially harmful medications, and support safer medication use among older adults.

The purpose of this paper is to examine how structured medication reconciliation can help reduce polypharmacy and potentially inappropriate medication use among older adults. This paper will discuss current research on medication reconciliation, medication review, and deprescribing, as well as the importance of patient education, communication, and collaboration among healthcare providers. The paper will also examine gaps in the literature and factors that may affect medication management in older adults. Based on the findings, the paper will propose a structured medication reconciliation intervention for Avicenna Medical Clinic, focusing on patients aged 65 years and older who take five or more medications. The role of the advanced practice registered nurse (APRN) in implementing the intervention and improving medication safety in primary care will also be discussed.

Operational Definitions

Polypharmacy. Polypharmacy is commonly defined as the use of five or more medications at the same time (Somerville et al., 2026). For this proposed intervention at Avicenna Medical Clinic, polypharmacy will be defined as taking five or more medications, including prescription medications, over-the-counter medications, and supplements. Patients aged 65 years and older who meet this criterion will be eligible for the structured medication reconciliation intervention. Taking multiple medications may increase the risk of medication-related problems, particularly when medications are prescribed by different healthcare providers.

Medication reconciliation. Medication reconciliation is the process of developing an accurate medication list and comparing the medications a patient is actually taking with the medications documented in the medical record. The process can be used to identify medication discrepancies, duplicate medications, medication interactions, and medications that may no longer be appropriate.

Medication review. Medication review is a structured evaluation of a patient's medications to determine whether each medication remains appropriate, effective, and safe. Medication review may also include evaluating medication dosage, interactions, adverse effects, adherence, and the patient's goals and preferences.

Potentially inappropriate medications. Potentially inappropriate medications (PIMs) are medications for which the potential risks may be greater than the expected benefits for an older adult, particularly when safer or more appropriate treatment options are available.

Deprescribing. Deprescribing is the planned process of reducing or discontinuing medications that may no longer be necessary, beneficial, or appropriate. The process may include tapering medications when needed and monitoring the patient after medication changes.

Older adults. For the purpose of this paper, older adults are individuals 65 years of age and older.

Primary care. Primary care refers to outpatient healthcare in which providers manage common acute and chronic health conditions, provide preventive care, manage medications, and coordinate care with other healthcare professionals and specialists

Background and Significance

Polypharmacy is a common concern among older adults, especially those who have multiple chronic conditions and receive care from different healthcare providers. Polypharmacy is commonly defined as taking five or more medications at the same time (Somerville et al., 2026). As older adults develop additional health conditions, they may receive new prescriptions from primary care providers and specialists. Over time, their medication lists may become longer and more difficult to manage. Some medications may remain on the list even when they are no longer necessary, while others may cause adverse effects or interact with medications prescribed by another provider. These concerns make regular medication review and reconciliation important for improving medication safety among older adults.

Primary care providers play an important role in identifying and managing polypharmacy because they often coordinate care for patients with multiple chronic conditions. However, older adults may receive prescriptions from several specialists, making it difficult to maintain an accurate medication list. Some patients may continue taking medications that were discontinued, take duplicate medications, or use over-the-counter products that are not documented in their electronic health records. Martinez et al. (2022) found that older adults in primary care took an average of 6.8 medications, with prescribing patterns varying among physicians. The study also found that physicians with lower prescribing rates had better medication reconciliation performance and prescribed fewer potentially inappropriate medications. These findings highlight the importance of reviewing medications regularly and improving communication between primary care providers, specialists, and patients.

Polypharmacy can increase the risk of medication-related problems and serious health complications among older adults. Taking multiple medications may increase the risk of drug interactions, adverse drug reactions, medication errors, falls, and confusion. According to the Centers for Disease Control and Prevention (CDC, 2024), adults aged 65 years and older have more than 600,000 emergency department visits each year because of adverse drug events. The CDC also reported that almost 500,000 people of all ages are hospitalized annually because of adverse drug events. These statistics show how medication-related problems can affect patient safety and increase healthcare use. Research also shows that medication review can help identify and reduce potentially inappropriate medications. For example, Gama et al. (2025) studied 319 hospitalized older adults with cardiovascular disease and found that potentially inappropriate medications decreased from 291 to 28 following pharmacist interventions. Although this study was conducted in a hospital, its findings support the importance of identifying unnecessary or potentially harmful medications. Regular medication reconciliation in primary care may help identify medication discrepancies and support safer medication use among older adults.

Review of Literature

The purpose of this review of literature was to examine current evidence regarding structured medication reconciliation and medication review as strategies for reducing polypharmacy and potentially inappropriate medication (PIM) use among older adults. Polypharmacy is particularly relevant to older adults because multimorbidity frequently results in medications being prescribed by multiple healthcare providers and specialists. Medication reconciliation provides an opportunity to compare the medications documented in the medical record with the medications the patient is actually taking and to identify duplication, unnecessary medications, inappropriate medications, medication interactions, and discrepancies. Two major themes emerged from the literature and organize this review. The first theme examines how structured medication review and reconciliation can reduce medication burden and potentially inappropriate medication use among older adults. The second theme examines the importance of interprofessional collaboration, patient education, and communication in making medication reconciliation effective.

A literature search was conducted to identify current research related to medication reconciliation and reducing polypharmacy in older adults. The main concepts used for the search were medication reconciliation, medication review, polypharmacy, potentially inappropriate medications, older adults, and deprescribing. Search terms included “medication reconciliation” OR “comprehensive medication review” OR “medication review,” AND “polypharmacy” OR “potentially inappropriate medications,” AND “older adults” OR “elderly” OR “geriatric.” The term “deprescribing” was also used to help identify studies evaluating interventions to reduce unnecessary medication use in older adults.

The literature search was conducted using PubMed and four databases available through EBSCOhost: CINAHL Complete, MEDLINE with Full Text, Health Source: Nursing/Academic Edition, and Alt HealthWatch. The search focused on research published within the past five years. In EBSCOhost, the search was limited to peer-reviewed articles published from August 25, 2021, through August 25, 2026, and secondary sources were excluded. After applying the search terms and filters, 98 articles remained. In PubMed, the search was limited to the past five years and filtered to include clinical trials, controlled clinical trials, pragmatic clinical trials, and randomized controlled trials. After applying these filters, 50 articles remained.

The inclusion criteria were peer-reviewed primary research studies published within the past five years, studies involving older adults with polypharmacy or potentially inappropriate medication use, and studies evaluating medication reconciliation, medication review, medication optimization, or deprescribing interventions. Studies were excluded if they were secondary sources, duplicates, study protocols without outcomes, scoping reviews, or studies that did not evaluate an intervention related to the clinical question. A total of 148 articles were identified, including 98 articles from EBSCOhost and 50 articles from PubMed. After title and abstract screening, 20 full-text articles were assessed for eligibility. Five full-text articles were excluded: two duplicate reports, one study protocol without outcomes, one scoping review/secondary source, and one study that did not evaluate an intervention. A total of 15 studies were included in the final literature review, consisting of 13 studies from PubMed and two unique studies from EBSCOhost databases.

Identification of studies via databases and registers

Duplicate records removed (n = 0) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 0)

Records identified through database searching EBSCOhost (n = 98) PubMed (n = 50) Total (n = 148)

Identification

Records screened

(n = 148)

Records excluded**

(n =128)

Reports sought for retrieval

(n = 20)

Reports not retrieved

(n = 0)

Screening

Reports assessed for eligibility

(n = 20)

Reports excluded (n = 5): Duplicate reports (n = 2) Study protocol/no outcomes (n = 1) Scoping review/secondary source (n = 1) Did not evaluate an intervention of interest (n = 1)

Studies included in review

(n = 15)

Reports of included studies

(n = 15)

Included

.

Thematic Synthesis

Structured Medication Review and Reconciliation Can Reduce Medication Burden and Potentially Inappropriate Medication Use

The reviewed studies demonstrate evidence of medication review reducing the number of medicines older people use and identifying potentially inappropriate medicines (PIMs) but the impact of the intervention is dependent upon the intervention and the outcome measured. Vasilevskis et al. (2023) evaluated the Shed-MEDS intervention in 372 older adults transitioning from hospitalization to postacute care. The intervention was led by a pharmacist or nurse practitioner who reviewed the patient's prescription medications, over-the-counter medications, and supplements to identify medications that might be unnecessary or potentially harmful. The clinician also discussed medication use, side effects, and treatment preferences with the patient or caregiver. Deprescribing recommendations were reviewed with the patient's prescribing providers and hospital treatment team before medication changes were made. After transfer to postacute care, the intervention clinician continued reviewing medications and followed up weekly with the facility. At discharge, the updated medication list and recommendations were communicated to outpatient providers. Patients in the intervention group had 14% fewer medications at postacute-care discharge and 15% fewer medications at the 90-day follow-up compared with usual care. These findings suggest that structured medication review, collaboration among healthcare providers, and continued follow-up may help reduce medication burden among older adults. However, because this intervention was conducted during the transition from hospitalization to postacute care, further research is needed to determine whether similar results can be achieved in primary care settings.

The findings of other randomized trials also support the benefit of structured medication review in decreasing inappropriate medication use, but medication reduction may not necessarily lead to better clinical outcomes. The STOPP/START criteria were used to assess a multi-disciplinary medication optimization protocol in hospitalized older adults (65 years or older) by Ie et al. (2024). There were no increased adverse drug events (ADEs) with the intervention, yet there was a reduction in the number of medications and PIMs, suggesting that medication reduction is possible while maintaining medication safety. But it did not lead to a significant improvement in the primary composite clinical outcome. Likewise, Jungo et al. (2023) evaluated a structured medication review intervention in primary care for older adults with multimorbidity and polypharmacy. The intervention used STRIPA, a web-based electronic clinical decision support system based on the STOPP/START criteria. The general practitioner entered and verified the patient’s medications, chronic conditions, laboratory values, and vital signs. STRIPA then identified potential medication overuse, underuse, misuse, drug-drug interactions, and inappropriate dosages and generated recommendations for the provider to review. The general practitioner decided which recommendations were appropriate and discussed the medication changes with the patient using shared decision-making. On average, 5.4 prescribing recommendations were generated per patient, and approximately one STOPP or START recommendation was implemented per patient. However, at 12 months, the results were inconclusive regarding whether the intervention improved overall medication appropriateness or reduced prescribing omissions compared with usual care. These findings suggest that electronic decision support can help identify medication-related problems and guide medication changes, although improvements in overall medication appropriateness may be limited.

Other studies showed different results in medication reduction, depending on the intervention and study design. Gama et al. (2025) conducted a before-and-after study involving 319 hospitalized older adults with cardiovascular disease in Brazil. Clinical pharmacists reviewed patients' medications and compared prescriptions at hospital admission and discharge to identify potentially inappropriate medications, polypharmacy, and prescribing omissions. Following the pharmacist interventions, the number of potentially inappropriate medications decreased from 291 to 28, and the average number of medications decreased from 9.8 to 6.5. However, because this study did not include a control group, the changes cannot be attributed entirely to the pharmacist intervention. In comparison, Abou et al. (2025) conducted a cluster randomized controlled trial and found that medication discontinuation occurred in 32% of intervention patients compared with 26% of control patients, but this difference was not statistically significant. Somerville et al. (2026) also found that individualized medication management support did not significantly reduce inappropriate medication use or improve adherence. These findings suggest that medication review may help reduce medication burden, but its effectiveness can vary depending on the setting, intervention, and patient population.

The primary care evidence highlights the need to review outcomes other than medication use. Gillespie et al. (2025) evaluated a GP-delivered individualized medication review for older adults with multimorbidity and polypharmacy. During the intervention, patients brought their medications to the visit, and the GP used the SPPiRE tool to screen for potentially inappropriate prescribing and conduct a brown-bag medication review. The GP discussed each medication with the patient, including its effectiveness, adverse effects, and actual use, and medication changes were made based on clinical judgment and the patient's priorities. The intervention resulted in a small but statistically significant reduction in the number of medications. However, the economic findings were promising but uncertain. Meurant et al. (2023) found that adding clinical medication review to standard pharmaceutical care in a geriatric ward did not significantly reduce potentially inappropriate medications or the total number of medications. However, the intervention helped address potentially omitted medications, particularly cardiovascular medications. Quek et al. (2023) evaluated a pharmacist-led deprescribing intervention among 303 older adults living in residential aged care facilities. Pharmacists completed an individualized medication review using an evidence-based deprescribing algorithm to identify medications that could potentially be discontinued. The medication withdrawal plan included the reason for deprescribing, the order of medication withdrawal, tapering when needed, and a monitoring plan. The recommendations were then reviewed by the patient’s GP before implementation. GPs accepted 77% of the pharmacists’ deprescribing recommendations, and 74% of the accepted recommendations were successfully implemented at 12 months. The number of regular medications was significantly reduced in both intervention groups, while remaining relatively unchanged in the control group. These findings demonstrate the value of collaboration between pharmacists and primary care providers when identifying and deprescribing unnecessary medications in older adults.

Interprofessional Collaboration, Patient Education, and Communication Are Important Components of Effective Medication Reconciliation

Effective medication reconciliation requires collaboration among healthcare professionals, clear communication, and active patient involvement. Research conducted across hospital, primary care, community pharmacy, and residential care settings shows that involving pharmacists, nurses, physicians, advanced practice providers, and patients can improve the medication review process. Lee et al. (2023) evaluated a pharmacist-led comprehensive medication reconciliation intervention in hospitalized adults aged 65 years and older who were taking at least five medications. Within 24 hours of admission, the pharmacist conducted a face-to-face interview and developed a complete medication list to identify medication discrepancies and potentially inappropriate medications (PIMs). During hospitalization, medications were reviewed using the Beers Criteria and STOPP/START criteria, and the pharmacist made recommendations to physicians regarding medication selection, dosage adjustment, drug interactions, and other medication-related problems. The intervention also included simplifying medication administration times and providing medication education before discharge. A total of 41 recommendations were made, and 83% were accepted. At the 30-day follow-up, no adverse drug events were reported in the intervention group, compared with five in the control group. These findings suggest that pharmacist-led medication reconciliation can help identify medication-related problems, simplify medication regimens, and improve medication safety in older adults. Communication among healthcare professionals during transitions of care was also emphasized by Grischott et al. (2023), who evaluated a medication review intervention at hospital discharge. However, medication optimization can go beyond just identifying the medications, as Vasilevskis et al. (2023) also noted in their patient-centered work with pharmacists and nurse practitioners, where patients are also involved in the decision-making process. Although Lee et al. (2023), Grischott et al. (2023), and Vasilevskis et al. (2023) examined medication-related interventions in hospital or transitional care settings, their findings may also have implications for primary care. Older adults often receive prescriptions from multiple providers, making communication and an accurate medication list important during routine office visits. In primary care, a structured medication reconciliation process could include confirming the medications patients actually take, identifying discrepancies, and discussing concerns with the prescribing providers. However, the effectiveness of these approaches in routine primary care needs further evaluation.

Shared decision making and communication were especially relevant in studies on implementation and perceptions of patients. Generally, older adults were satisfied with medication reviews and appreciated being prepared for the review, receiving follow-up, a collaborative approach, and shared decision making (Duncan et al., 2026). Hellemans et al. (2026) evaluated a pharmacist-led intervention that included medication reconciliation, medication review, patient counseling, and follow-up after discharge. The intervention was successfully implemented in 87% of patients. Medication reconciliation identified 1,364 medication discrepancies, and 85.8% of patients had at least one discrepancy. Pharmacists made 1,171 medication-related recommendations, and physicians immediately implemented 72.5% of these recommendations, resulting in an overall agreement rate of 89.5%. These findings demonstrate that a structured pharmacist-led intervention can identify medication discrepancies and support medication changes through collaboration among pharmacists, physicians, and other healthcare providers.

Research indicates that, despite collaboration, not all patients will have their medication altered or clinical results improve. The success of pharmacist recommendations depends on whether prescribers accept and implement the recommended medication changes. Similarly, Abou et al. (2025) highlighted the importance of communication between pharmacists and general practitioners but did not find a statistically significant difference in targeted medication discontinuation. The results suggest that while there is a need to communicate and collaborate for medication optimization, this alone is unlikely to lead to polypharmacy reduction.

Patient education supports medication reconciliation by helping older adults understand their medications and become more involved in medication-related decisions. Both Kornholt et al. (2022) and Somerville et al. (2026) integrated patient education into full-scope medication reviews and individualized medication-management support to overcome barriers faced by older people when taking their medicines. These approaches are important because medication reconciliation is not just about comparing a medication list to the medical record but about being able to recognize what medications a patient is taking, understand how they are being used, and communicate concerns or problems to the health care team. Individualized education can be useful in locating discrepancies that might not be evident on the electronic medication list and can provide patients with information that they need to be involved in decisions regarding continuing, changing, or stopping medications. Somerville et al. (2026) showed that individualized medication-management support resulted in fewer barriers and better medication-management performance, but was not associated with a significant reduction in inappropriate medication use or improvement in medication adherence. Thus, education seems to support the medication reconciliation process by increasing patient engagement and medication-management skills, but on its own, patient education does not seem to reduce PIM use or polypharmacy.

The literature suggests that interprofessional collaboration, clear communication, patient education, and shared decision making are important components of medication reconciliation, although these processes do not always result in significant reductions in medication use or improvements in clinical outcomes.

Synthesis and Gaps in the Literature

The literature consistently supports two interconnected findings. First, structured medication reconciliation and comprehensive medication review can help to decrease medication burden and medication use of potentially inappropriate medications (PIMs) among older adults. Secondly, interprofessional working, communication, patient education and shared decision making help to make these interventions more effective. There are a number of study constraints across the 15 studies reviewed that affect the validity and applicability of the evidence. Much of the research was carried out in hospitals, geriatric wards, residential care facilities or other specialized services, not in the routine primary care setting. This restricts the ability to conclude that the results of this would also apply to community-dwelling older adults cared for by several providers and specialists. Some studies also included small numbers of participants, short follow-up times, retrospective or uncontrolled designs, or were primarily feasibility and/or implementation studies, rather than studies of patient outcomes. For instance, Gama et al. (2025) showed significant decreases in medication burden and PIMs, but the study used an uncontrolled before-and-after design, which limits the ability to determine whether the intervention alone caused the changes. Medication-management barriers and performance improved in the study by Somerville et al. (2026), but they did not show a significant decrease in inappropriate medication use. Duncan et al. (2026) and Hellemans et al. (2026) similarly presented valuable data on satisfaction, feasibility, acceptability, and implementation without conclusively demonstrating clinical outcomes. Although these studies were conducted in hospital settings, some components of the interventions may also be useful in primary care. These include reviewing a complete medication list, identifying potentially inappropriate medications, discussing medication use with patients, and communicating recommendations to prescribing providers. However, primary care clinics have different workflows, staffing, and follow-up processes. Therefore, the findings from hospital-based studies cannot be directly generalized to primary care without further evaluation. This gap supports the need to examine how a structured medication reconciliation process could be implemented in a primary care setting.

Another key area of interest is the variation of the structure and delivery of medication reconciliation and medication review interventions. The variations in interventions across the studies included the professionals conducting the intervention, clinical decision-support tools used, involvement of pharmacists, deprescribing protocols, educational interventions, communication, and follow-up. Because the interventions varied across studies, it is difficult to determine which components are most important for an effective medication reconciliation process in primary care. Evidence in the literature is also less consistent with respect to outcomes other than the number of medications and the reduction of PIMs. Several studies reported the burden of the medication or inappropriate prescribing, but far fewer studies consistently measured discrepancies, adverse drug events, adherence to medications, education about them, quality of life, and long-term outcomes. However, some of these interventions were effective in changing medication use, while not showing improvements in overall clinical outcomes, suggesting that the number of medications is not a complete measure of the effectiveness of medication reconciliation.

Standardized and sustainable medication reconciliation processes should therefore be investigated in a future study specifically within primary care environments with high older adult populations. Medication reconciliation should be assessed using sufficiently large samples, comparison groups where appropriate, and longer follow-up periods to determine if it yields long-term benefits. Further research is needed to look at both individual and multiple outcomes such as discrepancies in medication, PIMs, medication burden, adverse drug events, patient understanding, adherence, and quality of life. Lastly, there is a need for further research to better understand the scope and role of APRNs in medication reconciliation and to explore how the practice of communication regarding medication information across the providers and care transitions can be shared. Closing these gaps would help support the use of structured medication reconciliation as routine practice in safe, patient-centered primary care with older adults.

Summary of Review of Literature

In summary, the reviewed literature shows that structured medication reconciliation and medication review can help reduce medication burden and potentially inappropriate medications in older adults (Ie et al., 2024; Kornholt et al., 2022; Vasilevskis et al., 2023). Several studies showed reductions in the number of medications or PIMs after structured medication review and deprescribing interventions. However, the results were not consistent across all studies, and some studies did not show significant improvement in clinical outcomes (Abou et al., 2025; Jungo et al., 2023). The literature also showed that communication and collaboration between providers, pharmacists, and patients are important parts of the medication review process (Duncan et al., 2026; Quek et al., 2023).

There are still several gaps in the literature. Many studies were conducted in hospitals, specialty settings, or outside of the United States, with fewer studies focusing on routine primary care. Some studies also had small sample sizes, short follow-up periods, or study designs that made it difficult to determine the long-term effectiveness of the interventions. The studies used different approaches to medication reconciliation and medication review, making it difficult to determine which components are most effective. There is also limited research examining the role of APRNs in leading these interventions in primary care.

Overall, the reviewed evidence supports structured medication reconciliation as an approach to reducing medication burden and potentially inappropriate medication use in older adults. The findings also show the importance of communication, collaboration, patient education, and shared decision-making as part of the medication review process. These findings provide support for developing a structured medication reconciliation approach that can be used in primary care with older adults.

Related Issues

Polypharmacy among older adults is influenced by several factors beyond the number of medications prescribed. Although medication reconciliation can help identify medication discrepancies and potentially inappropriate medications, other factors may affect how older adults manage their medications at home. These factors include health literacy, socioeconomic status, cultural beliefs, personal preferences, and family or caregiver involvement. Older adults may have difficulty understanding medication instructions, obtaining prescriptions, or communicating their medication use to healthcare providers. These challenges are especially important in primary care, where patients often receive medications from multiple providers and manage several chronic conditions. Therefore, understanding these related issues is important when developing a structured medication reconciliation intervention for older adults.

Health Literacy and Medication Understanding

Health literacy is an important factor in medication management among older adults with polypharmacy. Patients who have difficulty understanding medication instructions may not know why they are taking certain medications, how frequently they should take them, or whether medications should be continued. Some older adults may recognize their medications by color or appearance rather than by name. These difficulties can worsen when patients take multiple medications prescribed by different healthcare providers (Gillespie et al., 2023).

Gillespie et al. (2023) examined the relationship between health literacy, medication management, and decisions about deprescribing among older adults. Their mixed-methods study explored how older adults manage multiple medications in their daily lives and how health literacy may influence their decisions about medication changes. The study highlighted the importance of understanding patients' medication-management abilities and involving them in decisions about their medications. These findings are relevant because patients may have difficulty identifying medication-related problems even when they regularly attend medical appointments.

Similarly, Cho and Chang (2023) examined health literacy, self-efficacy, and medication adherence among 95 older adults with polypharmacy. Participants took an average of 8.32 medications daily. The researchers found that health literacy was generally low, but it was not significantly associated with medication adherence. However, higher self-efficacy was associated with better medication adherence. These findings suggest that understanding medications is important, but patients also need confidence in their ability to manage their medications correctly.

In primary care, medication reconciliation should include an assessment of how patients understand and manage their medications. Asking patients to bring their medication bottles to appointments may help providers identify medications that are missing from the electronic health record. Providers can also ask patients to explain how they take each medication and use simple written instructions when medication changes are made. These approaches may help identify medication discrepancies that would otherwise remain unnoticed.

Socioeconomic Factors and Medication Access

Socioeconomic factors can affect how older adults obtain and manage their medications. Medication costs, insurance coverage, transportation, and access to pharmacies may influence whether patients follow their prescribed treatment plans. Older adults who live on a limited income may have difficulty paying for several medications, especially when they have multiple chronic conditions. Some patients may delay filling prescriptions, skip doses, or stop taking medications because of financial concerns (Cohen & Mykyta, 2024).

Cohen and Mykyta (2024) examined prescription medication use, insurance coverage, and cost-related medication nonadherence among adults aged 65 years and older in the United States. Using data from the 2021–2022 National Health Interview Survey, the researchers found that 3.6% of older adults did not obtain needed prescription medications because of cost, while 3.4% did not take their medications as prescribed because of cost. Cost-related medication nonadherence was more common among older adults without prescription drug coverage and those experiencing food insecurity. These findings demonstrate that financial limitations can interfere with medication management even when medications have been appropriately prescribed.

These financial barriers are important during medication reconciliation because the medication list in the electronic health record may not represent what the patient is actually taking. For example, a medication may remain listed as active even when the patient has stopped taking it because of cost. If the healthcare provider does not ask about medication affordability, the reason for the discrepancy may not be identified.

Primary care providers can address these concerns by asking patients whether they have difficulty paying for or obtaining their medications. When appropriate, providers may consider less expensive alternatives, review medications that may no longer be necessary, or refer patients to medication-assistance programs. Transportation problems and limited access to pharmacies should also be considered, particularly among older adults who depend on others to obtain their prescriptions. Addressing these barriers can help make medication reconciliation more realistic and individualized.

Cultural Beliefs and Medication Preferences

Cultural beliefs and personal preferences may also influence medication use among older adults. Some patients may prefer natural remedies, herbal products, vitamins, or supplements in addition to their prescribed medications. Others may have concerns about long-term medication use or believe that medications should not be discontinued once they have been prescribed. These beliefs can affect how patients respond to medication changes and whether they discuss all medications and supplements with their healthcare providers.

Weir et al. (2024) examined medication adherence and willingness to deprescribe among 298 older adults with multimorbidity and polypharmacy in Swiss primary care. Participants reported generally high medication adherence and willingness to have medications deprescribed. However, the researchers did not find a significant association between willingness to deprescribe and medication adherence. These findings suggest that patients' attitudes toward stopping medications and their actual medication-taking behaviors are not necessarily related. Therefore, healthcare providers should assess each patient's preferences rather than assume that willingness to change medications reflects how medications are being taken.

Personal beliefs may also affect whether patients disclose medications obtained from other sources. Some older adults may use traditional remedies, herbal products, or supplements in addition to prescribed medications. Cultural beliefs and preferences can influence how patients perceive and discuss their medication use with healthcare providers (Hamed et al., 2025).

Language differences can create additional difficulties during medication reconciliation. Patients with limited English proficiency may have difficulty communicating about their medications or understanding changes made by their healthcare providers. Language support and clear communication may help improve medication understanding among patients with limited English proficiency (Hamed et al., 2025).

Primary care providers should ask about medication beliefs and preferences in a respectful manner. Patients should feel comfortable discussing their concerns, supplements, and traditional remedies without fear of being judged. This approach can help providers obtain a more complete medication history and involve patients in medication-related decisions.

Family and Caregiver Involvement

Family members and caregivers often play an important role in medication management among older adults. Some patients manage their medications independently, while others depend on family members to organize pillboxes, obtain refills, provide medication reminders, or administer medications. Caregiver involvement may become especially important when older adults experience cognitive impairment, vision problems, physical limitations, or difficulty managing complicated medication regimens (O'Conor et al., 2024).

O'Conor et al. (2024) conducted a qualitative study involving 32 older adults with mild cognitive impairment or dementia and their family caregivers. The researchers found that older adults with mild cognitive impairment or mild dementia often continued managing their medications independently, while caregivers provided some assistance. However, caregivers generally assumed greater medication-management responsibilities as cognitive impairment progressed. The transition of responsibility frequently occurred after caregivers noticed medication errors or other safety concerns. These findings suggest that caregiver involvement may be necessary before serious medication-management problems develop.

Family involvement can be beneficial, but it may also create difficulties when several people participate in medication management without clear communication. For example, one family member may organize medications while another obtains prescriptions or communicates with healthcare providers. If medication changes are not shared with everyone involved, outdated medication lists or duplicate medications may continue to be used.

Medication reconciliation should therefore include identifying who is responsible for managing the patient's medications at home. When appropriate and with the patient's permission, family members or caregivers should participate in medication discussions and receive updated medication instructions. However, the patient's independence and preferences should also be respected. This is especially important for older adults who are still capable of managing their medications but may need additional support.

Importance to Primary Care

The related issues discussed above demonstrate that medication reconciliation involves more than reviewing the medication list in the electronic health record. Health literacy, financial limitations, cultural beliefs, and caregiver involvement can influence how medications are actually used at home. These factors may contribute to medication discrepancies even when the medications prescribed are clinically appropriate.

Primary care providers are in a position to identify these concerns because they often manage several chronic conditions and maintain ongoing relationships with older adults. A structured medication reconciliation process should include questions about medication understanding, affordability, over-the-counter medications and supplements, and caregiver involvement. Identifying these issues may help providers understand why medication discrepancies occur and develop a treatment plan that patients can realistically follow.

Overall, addressing these related issues is important when developing a medication reconciliation intervention for older adults. A patient-centered approach that considers individual needs and barriers may improve medication safety and support more appropriate medication use in primary care.

Theoretical Frameworks and Conceptual Models

The Iowa Model of Evidence-Based Practice (EBP) provides a structured approach for applying research findings to clinical practice. The model helps healthcare professionals identify problems, evaluate available evidence, develop practice changes, and assess whether those changes improve patient care. The revised Iowa Model emphasizes collaboration, patient involvement, and the importance of maintaining successful changes over time (Iowa Model Collaborative et al., 2017). This framework was selected for the proposed project because improving medication reconciliation requires more than identifying medication discrepancies. It also requires a consistent process that can be incorporated into routine primary care visits.

The Iowa Model begins with identifying a problem or opportunity for improvement and determining whether it is a priority for the organization. For this project, the identified concern is the lack of a consistent medication reconciliation process that may contribute to unrecognized medication discrepancies and unnecessary medication use among older adults. At Avicenna Medical Clinic, the proposed intervention would focus on patients aged 65 years and older who take five or more medications. The next step would involve bringing together the healthcare team to examine current practices and identify areas where medication information may be incomplete or inaccurate. This would help determine how a standardized process could fit into the clinic's existing workflow.

The model also emphasizes reviewing and evaluating available evidence before introducing a practice change (Iowa Model Collaborative et al., 2017). The literature reviewed in this paper supports structured medication review, communication among healthcare providers, and patient participation as important components of medication safety. However, the studies also demonstrate differences in how these interventions are delivered and evaluated. Therefore, the proposed intervention would need to be adapted to the resources and responsibilities of a primary care clinic rather than directly adopting a hospital-based approach.

Following the evidence review, the Iowa Model recommends testing the proposed practice change before implementing it more broadly. In this project, a standardized medication reconciliation process could be introduced during routine visits for eligible older adults. The process would involve confirming the medications patients actually take, comparing them with the electronic health record, identifying discrepancies, and communicating medication-related concerns to the prescribing provider. Patients would also receive education about maintaining an accurate medication list. The purpose would not be to discontinue medications simply because a patient takes several prescriptions, but to identify medications that may require further review and support safer medication management.

Evaluation would help determine whether the proposed intervention is practical and effective. Possible measures would include the percentage of eligible patients who receive a completed medication reconciliation, the number of medication discrepancies identified, and the number of concerns communicated to prescribing providers. The healthcare team could also evaluate whether the process creates difficulties related to appointment time, documentation, or communication. If the intervention demonstrates improvement, the Iowa Model supports incorporating the process into routine practice and continuing to monitor outcomes (Iowa Model Collaborative et al., 2017). Using this framework would provide a systematic way to introduce and evaluate medication reconciliation at Avicenna Medical Clinic while allowing the process to be adjusted according to the needs of patients and staff.

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